Submission of this Plan of Correction does not constitute an admission or agreement by the ...

114 Pages·2012·0.35 MB·English

PRINTED: 06/19/2013
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 00 COMPLETED
A. BUILDING
155323 05/31/2013
B. WING
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
410 TIOGA RD
WHISPERING PINES REHABILITATION CENTRE MONTICELLO, IN 47960
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5)
PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
CROSS-REFERENCED TO THE APPROPRIATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG DEFICIENCY) DATE
F000000

This visit was for a Recertification and F000000 Submission of this Plan of
State Licensure Survey. This visit Correction does not
included the Investigation of constitute an admission or
Complaint IN00129035. agreement by the provider
of the truth of facts alleged
Complaint IN00129035- or corrections set forth on
Substantiated. No deficiencies the statement of
related to the allegation were cited. deficiencies.

Survey dates: May 27, 28, 29, 30, This Plan of Correction is
and 31, 2013 prepared and submitted
because of requirements
Facility number: 000216 under State and Federal
Provider number: 155323 law.
AIM number: 100267580
Please accept this plan of
Survey team: correction as our credible
Regina Sanders, RN, TC (May 28, 29, allegation of compliance.
30, and 31, 2013)
Shannon Pietraszewski, RN (May 29,
30, and 31, 2013)
Amber Bloss, QIDP (May 28, 29, 30,
and 31, 2013)
Janelyn Kulik, RN (May 27 and 28,
2013)
Cyndy Stramel, RN (May 28, 29, 30,
and 31, 2013)
Janet Adams, RN (May 28, 29, 30,
and 31, 2013)
Census bed type:
SNF/NF: 48
Total: 48
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determined that
other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to
continued program participation.
_____________________________________________________________________________________________________
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9UAU11 Facility ID: 000216 If continuation sheet Page 1 of 114
PRINTED: 06/19/2013
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 00 COMPLETED
A. BUILDING
155323 05/31/2013
B. WING
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
410 TIOGA RD
WHISPERING PINES REHABILITATION CENTRE MONTICELLO, IN 47960
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5)
PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
CROSS-REFERENCED TO THE APPROPRIATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG DEFICIENCY) DATE
Census Payor type:
Medicare: 05
Medicaid: 38
Other: 05
Total: 48
There deficiencies reflect State
findings cited in accordance with 410
IAC 16.2.
Quality review completed on June 6,
2013, by Janelyn Kulik, RN.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9UAU11 Facility ID: 000216 If continuation sheet Page 2 of 114
PRINTED: 06/19/2013
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 00 COMPLETED
A. BUILDING
155323 05/31/2013
B. WING
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
410 TIOGA RD
WHISPERING PINES REHABILITATION CENTRE MONTICELLO, IN 47960
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5)
PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
CROSS-REFERENCED TO THE APPROPRIATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG DEFICIENCY) DATE
F000157 483.10(b)(11)
SS=D NOTIFY OF CHANGES
(INJURY/DECLINE/ROOM, ETC)
A facility must immediately inform the
resident; consult with the resident's
physician; and if known, notify the resident's
legal representative or an interested family
member when there is an accident involving
the resident which results in injury and has
the potential for requiring physician
intervention; a significant change in the
resident's physical, mental, or psychosocial
status (i.e., a deterioration in health, mental,
or psychosocial status in either life
threatening conditions or clinical
complications); a need to alter treatment
significantly (i.e., a need to discontinue an
existing form of treatment due to adverse
consequences, or to commence a new form
of treatment); or a decision to transfer or
discharge the resident from the facility as
specified in §483.12(a).
The facility must also promptly notify the
resident and, if known, the resident's legal
representative or interested family member
when there is a change in room or
roommate assignment as specified in
§483.15(e)(2); or a change in resident rights
under Federal or State law or regulations as
specified in paragraph (b)(1) of this section.
The facility must record and periodically
update the address and phone number of
the resident's legal representative or
interested family member.
Based on record review, the facility F000157 06/30/2013 12:00:00AM
F157
failed to notify a resident's physician, 1.  Resident #26-The resident’s 
related to a resident's poor appetite attending physician assessed the 
and fluid intake for 4 days, which the resident on 4/24/13 and the IV fluids 
were discontinued.  The resident 
resident was then transferred to the
was assessed for dehydration with 
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9UAU11 Facility ID: 000216 If continuation sheet Page 3 of 114
PRINTED: 06/19/2013
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 00 COMPLETED
A. BUILDING
155323 05/31/2013
B. WING
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
410 TIOGA RD
WHISPERING PINES REHABILITATION CENTRE MONTICELLO, IN 47960
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5)
PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
CROSS-REFERENCED TO THE APPROPRIATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG DEFICIENCY) DATE
hospital emergency room and was no findings.
treated for dehydration, for 1 of 18 2. The food and fluid 
residents reviewed for physician consumption records for all 
residents have been reviewed to 
notification in a total sample of 26.
determine if any other residents 
(Resident #26)
require physician intervention.  Any 
concerns identified will be 
Findings include:
immediately addressed.
3. The nursing staff have been 
Resident #26's record was reviewed re-educated on monitoring of the 
on 05/30/13 at 9:45 am. The food/fluid consumption records. Any 
residents identified as not eating or 
resident's diagnoses include, but
refusing fluids will be reported 
were not limited to, dementia,
through the 24 hour report sheet.  
diabetes mellitus, and chronic kidney
The licensed nursing staff have been 
disease.
re-educated on the facility policy 
and procedure for physician 
A Nutritional Assessment Form, dated notification.  The Director of Nursing 
04/18/13, indicated the resident's (DON) or designee will audit the 
calorie needs were 1995 calories per 24hr report 5x weekly  and the food 
and fluid consumption records 2x 
day and fluid needs were 2375 cc of
weekly to ensure compliance.
fluids per day.
4. The DON will report the 
results of these audits and any 
The Food Acceptance Record, dated corrective actions taken to the QA 
04/13, indicated the following food committee monthly x 3 months and 
and fluid intakes: quarterly thereafter, and revisions 
4/19/13: breakfast- 0 (marked with a made to the plan, if warranted.
5. 6/30/13
*)
lunch- 0 (marked with a *)
supper - bites and fluid intake
was sips
4/20/13: breakfast- 0 (marked with a
*)
lunch- 0 (marked with a *)
supper- 100% and fluid intake
was 360 cc (cubic centimeters)
total fluid intake for the day
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9UAU11 Facility ID: 000216 If continuation sheet Page 4 of 114
PRINTED: 06/19/2013
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 00 COMPLETED
A. BUILDING
155323 05/31/2013
B. WING
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
410 TIOGA RD
WHISPERING PINES REHABILITATION CENTRE MONTICELLO, IN 47960
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5)
PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
CROSS-REFERENCED TO THE APPROPRIATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG DEFICIENCY) DATE
was 360 cc
4/21/13: breakfast- 25% and fluid
intake was 240 cc
lunch-25% and fluid intake
was 60 cc
supper- 25% and fluid intake
was 60 cc
total fluid intake for the day
was 360 cc
4/22/13: breakfast- refused food and
fluid
lunch- 25% and fluid intake
was 180 cc
supper- refused
total fluid intake for the day
was 180 cc
4/23/13: breakfast- refused
lunch- refused (then resident
sent to the hospital)
The Nurses Notes indicated:
4/19/13 at 4:35 p.m.- "MD (physician)
contacted r/t (related to) her (sic)
wound...request sent to start mvi
(multiple vitamin) et (and) vit (vitamin)
C for wound healing..."
4/21/13 at 10 p.m.-"...refused all of
eve (evening) meal & substitute."
4/22/13 at 3 p.m.-"...decreased (arrow
down) ability to perform ADLs
(activities of daily living). MD notified
c/ (with) response pending..."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9UAU11 Facility ID: 000216 If continuation sheet Page 5 of 114
PRINTED: 06/19/2013
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 00 COMPLETED
A. BUILDING
155323 05/31/2013
B. WING
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
410 TIOGA RD
WHISPERING PINES REHABILITATION CENTRE MONTICELLO, IN 47960
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5)
PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
CROSS-REFERENCED TO THE APPROPRIATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG DEFICIENCY) DATE
4/23/13 at 11:50 a.m.- "Res (resident)
displaying increased (arrow up)
weakness, change (triangle) in LOC
(level of conscienceness), overall
decline c/ (with) ADL's. Res has
requested to be seen in er...Report
called to ER..."
There was a lack of documentation to
indicate the resident's physician had
been notified of the resident's poor
food and fluid intake.
A facility policy, dated 01/06, titled,
"Physician & Family Notification
Procedure", received from the
Director of Nursing as current,
indicated, "...To keep the physician,
resident and family appraised of all
condition changes...Telephone: 1.
Telephone notification is required for
all emergencies or all condition
changes that require an immediate
response...Document information to
be faxed...Include all assessment
information that the physician will
need to make his decisions..."
3.1-5(a)(3)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9UAU11 Facility ID: 000216 If continuation sheet Page 6 of 114
PRINTED: 06/19/2013
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 00 COMPLETED
A. BUILDING
155323 05/31/2013
B. WING
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
410 TIOGA RD
WHISPERING PINES REHABILITATION CENTRE MONTICELLO, IN 47960
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5)
PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
CROSS-REFERENCED TO THE APPROPRIATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG DEFICIENCY) DATE

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9UAU11 Facility ID: 000216 If continuation sheet Page 7 of 114
PRINTED: 06/19/2013
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 00 COMPLETED
A. BUILDING
155323 05/31/2013
B. WING
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
410 TIOGA RD
WHISPERING PINES REHABILITATION CENTRE MONTICELLO, IN 47960
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5)
PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
CROSS-REFERENCED TO THE APPROPRIATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG DEFICIENCY) DATE
F000176 483.10(n)
SS=D RESIDENT SELF-ADMINISTER DRUGS IF
DEEMED SAFE
An individual resident may self-administer
drugs if the interdisciplinary team, as defined
by §483.20(d)(2)(ii), has determined that this
practice is safe.
Based on observation, record review F000176 06/30/2013 12:00:00AM
F176
and interview the facility failed to 1.  Resident # 37-The OTC 
ensure a resident was assessed to arthritis cream was removed from 
self-administer medications related to the room when the facility became 
aware.  The resident was 
arthritis cream kept in a resident's
re-educated on not obtaining 
room for 1 of 26 residents reviewed
medications while out on leave.  The 
for self-administration of medications
MD was contacted and an order was 
in a total sample of 26.(Resident #
obtained for the arthritis cream.  A 
37). self-administration assessment was 
completed and it was determined 
Findings include: the arthritis cream would be applied 
by the nursing staff. 
2. The facility completed an 
On 5/30/13 at 8:30 a.m. there were
observation of all other resident 
two tubes of an over the counter
rooms to ensure no other 
(OTC) arthritis cream observed in the
medications were present at the 
resident's bedside table drawer. One bedside.  Any identified concerns 
tube was half empty, the other was were immediately corrected.
unopened. The resident indicated he 3. The Administrator and/or 
used the cream on his knees. designee will conduct a visual 
inspection of the resident rooms 

including drawers, with 
On 5/31/13 at 8:00 a.m. there were
resident/responsible party 
two tubes of an OTC arthritis cream in
permission, at least 1x weekly to 
the resident's bedside table drawer.
ensure compliance.
4. The Administrator and/or 
The record for Resident # 37 was designee will report the findings of 
reviewed on 5/30/13 at 9:00 a.m. The these inspections and any corrective 
actions taken to the QA committee 
resident's diagnoses included, but
monthly x 3 months and quarterly 
were not limited to, type 2 diabetes,
thereafter, and revisions made to 
neuropathy, and dementia.
the plan, if warranted.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9UAU11 Facility ID: 000216 If continuation sheet Page 8 of 114
PRINTED: 06/19/2013
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 00 COMPLETED
A. BUILDING
155323 05/31/2013
B. WING
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
410 TIOGA RD
WHISPERING PINES REHABILITATION CENTRE MONTICELLO, IN 47960
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5)
PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
CROSS-REFERENCED TO THE APPROPRIATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG DEFICIENCY) DATE
5. 6/30/13
The resident's record lacked
documentation to indicated the
resident had an order for the arthritis
cream and an order to self-administer
the arthritis cream.
There was a lack of documentation in
the resident's record to indicate an
assessment was completed by the
facility to determine if the resident
could safely self administer
medications.
During an interview with LPN # 1 on
5/30/13 at 2:15 p.m. she indicated the
resident would go to the store with
family members and sometimes bring
back items that the staff would have
to remove from his room. The LPN
indicated she did not know the
resident had OTC arthritis cream in
his room.
During an interview with the
Administrator on 5/31/13 at 8:17 a.m.,
she indicated resident's were to have
an assessment for self administration
of medications and a physician's
order for OTC medications kept in
their room.
During an interview with DoN
(Director of Nursing) on 5/31/13 at
8:50 a.m., she indicated the resident
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9UAU11 Facility ID: 000216 If continuation sheet Page 9 of 114
PRINTED: 06/19/2013
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 00 COMPLETED
A. BUILDING
155323 05/31/2013
B. WING
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
410 TIOGA RD
WHISPERING PINES REHABILITATION CENTRE MONTICELLO, IN 47960
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5)
PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
CROSS-REFERENCED TO THE APPROPRIATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG DEFICIENCY) DATE
was not assessed to self-administer
medications.
The document titled "Self
Administration of Medication
Procedure" dated 9/05 was provided
by the Director of Nursing on 5/31/13
at 2:50 p.m. and was identified as
current policy. The policies
procedure indicated "...2. An
assessment of the residents abilities
to self-administer meds (medications)
[sic] will be completed prior to
initiation of training. 3. Training for
self-administration will begin after the
HCP team, Physician and responsible
party have deemed appropriate...5.
Until a determination is made the
facility will administer all
medications."
3.1-11(a)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9UAU11 Facility ID: 000216 If continuation sheet Page 10 of 114